SRSR 2020 - 1-day Rider Registration - Red Sky Ride 2020

Name*

First Last

Date of Birth*

Company

Occupation

Mobile No*

Alternate contact no

Email*

Postal Address

Address*

Street Address Address Line 2 City State Postcode

License details

License no.

Expiry date

Class

Medical details

Please list below any medical conditions, injuries and/or allergies:

Please list any dietary requirements:

Medicare No.

Health Insurance

Membership No.

In case of emergency, contact information.

Name*

First Last

Mobile*

Alternate contact no.

GP Contact details

General Practitioner

Contact No.

Do you have any first aid or medical training?*

If Yes, please specify training type:

Rider Route

Final Stage*

Price: $ 600.00

Subsequent Stages

$150.00 per additional stage

Single Stage Participation = $600.00

Raise a targeted amount of $500.00 and support fundraising events
Includes: Red Sky Ride jersey only, on route support, ride snacks, fluids and lunch, 1 night’s accommodation, evening meal and breakfast the following morning.

Select Accomodation options

Additional accommodation

$150.00 per person/per night

No of persons requiring accomodation*

Options for riders and partners **

1 night’s accommodation, evening meal and breakfast the following morning
$150.00 per person /per night

** Subject to availability

Night stay

Bunbury
No selection

Total payable

$ 0.00

Payment Details

CHEQUE

Enclosed is my cheque or money order payable to Red Sky Ride

DIRECT DEPOSIT

Attached is a copy of my bank receipt for a direct deposit to: Bank: Westpac
Account Name: Red Sky Ride
BSB 036-304
Account 233 174

Upload bank receipt

This can be emailed later to michelle.hilder@solariscare.org.au

CREDIT CARD

Name on card

Credit or debit card no.

Expiry date

CVV

PAYPAL

Pay via PayPal

Read Terms & Conditions here.

SRSR 2020 – 1-day Rider Registration